Healthcare Provider Details

I. General information

NPI: 1932976586
Provider Name (Legal Business Name): ETHAN JOHN ZAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 UNIVERSITY AVE
DES MOINES IA
50311-4516
US

IV. Provider business mailing address

1100 25TH ST
DES MOINES IA
50311-4208
US

V. Phone/Fax

Practice location:
  • Phone: 515-271-2011
  • Fax:
Mailing address:
  • Phone: 402-853-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: